Provider Demographics
NPI:1962643072
Name:MY MASSAGE SANCTUARY, INC
Entity Type:Organization
Organization Name:MY MASSAGE SANCTUARY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:I
Authorized Official - Last Name:KAYSER
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:815-301-7809
Mailing Address - Street 1:101 NORTH ALPINE ROAD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107
Mailing Address - Country:US
Mailing Address - Phone:779-423-1700
Mailing Address - Fax:866-596-1027
Practice Address - Street 1:101 NORTH ALPINE ROAD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107
Practice Address - Country:US
Practice Address - Phone:779-423-1700
Practice Address - Fax:866-596-1027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.003938174400000X
IL198.000709261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty